Methods and devices for laparoscopic surgery

ABSTRACT

Two part laparoscopic tools and surgical methods using such tools are presented. The tools and methods enable use of multiple surgical tools each having wide tool heads to be used in a body cavity using a single wide trocar and one or more narrow incisions, thereby reducing surgical risk and enhancing patient comfort and shortening recovery time. Additional instruments for facilitating laparoscopic surgery are also presented.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.14/831,424, filed Aug. 20, 2015, which is a continuation of U.S.application Ser. No. 12/781,831, filed on May 18, 2010, which claims thebenefit of priority under 35 U.S.C. §119(e) of U.S. ProvisionalApplication No. 61/179,413, filed on May 19, 2009, the contents of whichare incorporated herein by reference in their entireties.

FIELD AND BACKGROUND OF THE INVENTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery.

Laparoscopic surgery (one form of minimally invasive surgery (MIS), alsoknown as band-aid surgery, keyhole surgery, or pinhole surgery) is amodern surgical technique with many advantages over traditional opensurgical methods. The first use of this approach in order to perform acholecystectomy was in 1987. Since that time, the procedure has gainedpopularity and is now regularly used in many different operations withinthe abdominal and pelvic cavities as well as for thoracoscopic andorthopedic surgery.

In existing laparoscopic methods, a variety of different instruments areused, including graspers, scissors, coagulation devices, harmonicscalpels, needle holders, cameras, suction devices and so on. Aplurality of such instruments may be required in a single procedure,with each instrument requiring its own trocar, which both acts as anentry port and facilitates manipulation of the devices within theabdominal cavity or other operative site. In general, laparoscopicoperations are usually performed by inserting 2-6 trocars (ports) intothe abdominal cavity, each through an incision in the skin.

The trocars usually range in size from 5 mm to 12 mm in diameter, eachserving as an introduction channel for one or more surgical tools.However, the use of trocars carries risks during both insertion andremoval. The risks include:

-   -   damage to blood vessels in the abdominal walls (particularly in        overweight patients);    -   damage to fascial tissues;    -   extended and painful recovery period;    -   visible scarring;    -   relatively high cost;    -   time consuming; and    -   post-operative ventral hernia (POVH), particularly when the        larger trocars are used.

Most of the aforementioned risks and disadvantages are associated withthe relatively large size of the incision required for trocar insertion.

SUMMARY OF THE INVENTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery. More specifically, thepresent invention provides two-part laparoscopic tools which may beinserted into the body using fewer and/or smaller incisions than thoseused according to methods of prior art, and other tools for facilitatinglaparoscopic surgery. Embodiments of the invention significantly reducesurgical risks, simplify surgical procedures, and facilitate rapidpatient recovery.

The methods include performing laparoscopic interventions using one ormore multi-part instruments, wherein each instrument comprises a shaft(optionally with handle) and one or more operating tools (also called“operating heads” and “operating tool heads”) attachable to that shaft.The shafts have a cross-section considerably smaller than mostlaparoscopic tools of prior art and are designed for direct insertioninto the body cavity by puncture penetration or through a relativelysmall incision, rather than through a conventional laparoscopic port.The handles comprise a screw thread or other attaching mechanism attheir distal ends, suitable for attaching an operating head thereto.

In the following the term “wide trocar” refers to a trocar wide enoughto enable passage of an operating tool. A typical internal diameter of awide trocar would be 4 mm or larger, though that size is not to beconsidered limiting. In the following the term “narrow trocar” refers toa trocar only wide enough to enable passage of a shaft to which anoperating tool may be attached. A typical internal diameter of a “narrowtrocar” would be 3 mm or less, though that size should not be consideredlimiting.

Various embodiments presented herein enable providing a plurality ofoperating tools each connected to an individual shaft and able to beoperated independently, using only a single wide trocar, by introducinga plurality of operating tools into the body cavity through the widetrocar, and introducing shafts for those operating tools either throughnarrow trocars or by using a shaft (optionally with an insertedstiffener) to directly puncturing the cavity wall, thereby creatingopenings substantially similar in size to the diameter of the shaft.Such openings are considerably smaller than the opening required for awide trocar, and consequently are less damaging and provide fewercomplications, shortened recovery time and less bleeding and lessscarring.

Embodiments presented herein include methods for attaching an operatingtool to shaft and optionally also to a manipulating handle, including:

a) introducing a distal portion of a shaft into a body cavity, forexample by puncturing a wall of the cavity or by introducing the handlethrough the wall by means of a narrow trocar, introducing an operatingtool into the body cavity through a wide trocar, and connecting tool toshaft within the body cavity,

b) introducing a distal portion of a shaft into a body cavity, forexample by puncturing a wall of the cavity or by introducing the handlethrough the wall by means of a narrow trocar, extending the distal shaftportion towards and into a wide trocar, advancing the distal shaftportion through the wide trocar so that the distal shaft portion exitsthe body cavity through the wide trocar, attaching an operating tool tothat distal shaft portion while the distal shaft portion is outside thebody, and then withdrawing the shaft so that the attached operating toolis retracted into the body cavity where it can be used, and

c) attaching an operating tool to a shaft, the shaft optionally having asharp proximal end, introducing the shaft into a wide trocar, extendingit towards an inner portion of a body cavity wall, causing the shaft totraverse to body cavity wall so that the proximal shaft extends outsidethe body cavity, connecting a handle to the shaft portion which isexternal to the body cavity, and withdrawing the shaft far enough fromthe body so that the operating tool is drawn through the wide trocar andinto the body cavity, where it can be used.

The operating tools (also called “operating heads” herein) may be anysurgical tools, including (but not limited to) graspers, scissors,coagulation devices, harmonic scalpels, LigaSure, needle holders,ligatures, cameras and suction devices. The operating heads mayoptionally have shaft diameters similar to, or larger than, those ofconventional laparoscopic tools. According to some embodiments ofmethods of use, a plurality of these operating heads may be insertedinto the body (e.g. sequentially, through a single trocar port ofconventional design, or Gastro-Colonoscopically using a Natural OrificeTransluminal Endoscopic Surgery (NOTES) instrument) and may be matedwith and attached to their shafts within the body cavity. In alternativeembodiments one or more of such shafts may be inserted into the bodycavity, extended out of the body cavity (e.g. sequentially) through asingle trocar or a reduced number of trocars, attached to an operatinghead outside the body, and thence drawn back into the body cavitythrough the trocar. With either of these methods, the result is aplurality of narrow shafts penetrated into the body cavity throughpunctures or insertions which are smaller than typical trocar diameters,each shaft mated to an operating head, which may be any conventionalsurgical tool of normal diameter and capabilities. Additional operatingheads may be introduced into the body cavity and operating heads may beswitched and exchanged, all within the body cavity, during the course ofan operation. A plurality of surgical tools are thereby made availablefor manipulation and use within a body cavity, though only a reducednumber of trocars (optionally only one) have been used.

Some embodiments of the present invention further comprise

-   -   tools for managing a plurality of operating heads within the        body cavity, comprising a plurality of connecting elements each        able to hold an operating head, and further comprising a        penetrating element operable to penetrate a body wall from        within the body cavity, and to extend beyond the body where it        may be grasped and immobilized from outside the body;    -   tools for inserting operating heads into the body cavity and/or        for removing operating heads from a body cavity, optionally        implemented as a sheath adaptable over a camera assembly        introduced into a body through a trocar;    -   tools for removing body tissues or other objects from the body        cavity during an intervention, comprising a sheath (optionally        adaptable over a camera assembly introduced into the body        through a trocar) and a rolled or folded bag which may be        introduced into the body cavity through the sheath, unrolled or        unfolded within the body cavity, filled with materials to be        extracted, and then withdrawn from the body through the trocar;    -   tools for stabilizing and/or immobilizing and/or positioning        body organs or other tissues during a surgical intervention        comprising a narrow shaft having a distal portion insertable        into the body cavity and connectable to an operating head, and a        stabilizing/positioning mechanism connected proximal portion of        the shaft outside the body and designed to stabilize the shaft        in a selected position; and    -   several grasper designs with detachable heads, some including a        head mechanism presenting advantages over head mechanisms known        to prior art.

It is noted embodiments of the present invention include (and are notlimited to) the above-listed components and embodiments used bothseparately and/or in concert, and further include additional componentsand embodiments as detailed below. It is further noted that the “wide”and “narrow” tools described in detail below may be used individually orin sets of several such tools used individually and/or in concert, andthat one or more “wide” tools may be used alone or in concert with oneor more “narrow” tools. It is further noted that the invention is notlimited to the specific exemplary uses described for the discloseddevices, and that the invention is also not limited to the specificallydescribed exemplary tool examples described as being used to perform thedisclosed methods.

Unless otherwise defined, all technical and/or scientific terms usedherein have the same meaning as commonly understood by one of ordinaryskill in the art to which the invention pertains. Although methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of embodiments of the invention, exemplarymethods and/or materials are described below. In case of conflict, thepatent specification, including definitions, will control. In addition,the materials, methods, and examples are illustrative only and are notintended to be necessarily limiting.

BRIEF DESCRIPTION OF THE DRAWINGS

Some embodiments of the invention are herein described, by way ofexample only, with reference to the accompanying drawings. With specificreference now to the drawings in detail, it is stressed that theparticulars shown are by way of example and for purposes of illustrativediscussion of embodiments of the invention. In this regard, thedescription taken with the drawings makes apparent to those skilled inthe art how embodiments of the invention may be practiced.

In the drawings:

FIGS. 1A and 1B are simplified schematics of a two-part laparoscopictool, according to an embodiment of the present invention;

FIGS. 2, 3, 4 and 5 are simplified schematics showing components of thetool shown in FIGS. 1A and 1B;

FIGS. 6A and 6B are simplified schematics showing a hollow grasper head;

FIGS. 6C, 6D and 6E show uses for the hollow grasper head shown in FIGS.6A and 6B, according to embodiments of the present invention;

FIG. 7 is a schematic of a laparoscopic tool with electrical functions,according to an embodiment of the present invention;

FIG. 8 is a narrow laparoscopic tool according to an embodiment of thepresent invention;

FIG. 9 is a grasper head showing opening and closing of the grasper,according to an embodiment of the present invention;

FIG. 10 shows several views of an additional construction of a grasperhead according to an embodiment of the present invention;

FIGS. 11A, 11B, 11C and 11D show details of connection between a shaftand a handle, according to an embodiment of the present invention;

FIG. 12 presents a immobilization device for surgery according to anembodiment of the present invention;

FIG. 13 presents a tool for manipulating operating heads within a bodycavity;

FIGS. 14 and 15 present examples of the use of the tool shown in FIG.13, according to an embodiment of the present invention;

FIGS. 16, 17 and 18 present several embodiments of a tool for removingmaterials from a body cavity, according to an embodiment of the presentinvention;

FIG. 19 presents a tool for organizing treatment heads within a bodycavity;

FIGS. 20, 21 and 22 present stages in the use of the tool shown in FIG.19, according to an embodiment of the present invention;

FIG. 23 presents a method for attaching a treatment head to a shaftaccording to an embodiment of the present invention;

FIGS. 24, 25, 26, 27, 28 and 29 present stages in a process forintroducing and using a surgical tool with a wide head in a body cavityusing only a small incision, according to an embodiment of the presentinvention;

FIG. 30 presents an optional enhancement to the method shown in FIGS.24-29, according to an embodiment of the present invention; and

FIGS. 31, 32, 33, 34, 35, 36, 37, 38 and 39 present aspects of asurgical procedure whereby a tool with wide operating head and narrowshaft may be introduced into a body cavity, according to an embodimentof the present invention.

DETAILED DESCRIPTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery. More specifically, thepresent invention provides two-part laparoscopic tools which may beinserted into the body using fewer and/or smaller incisions than thoseused according to methods of prior art, and other tools for facilitatinglaparoscopic surgery. Embodiments of the invention significantly reducesurgical risks, simplify surgical procedures, and facilitate rapidpatient recovery.

Before explaining at least one embodiment of the invention in detail, itis to be understood that the invention is not necessarily limited in itsapplication to the details of construction and the arrangement of thecomponents and/or methods set forth in the following description and/orillustrated in the drawings and/or the Examples. The invention iscapable of other embodiments or of being practiced or carried out invarious ways.

It is expected that during the life of a patent maturing from thisapplication many relevant laparoscopic tools will be developed and thescope of the terms “laparoscopic tool”, “operating tool” and “operatinghead” are intended to include all such new technologies a priori.

The terms “comprises”, “comprising”, “includes”, “including”, “having”and their conjugates mean “including but not limited to”.

The term “consisting of means “including and limited to”.

As used herein, the singular form “a”, “an” and “the” include pluralreferences unless the context clearly dictates otherwise. For example,the term “a compound” or “at least one compound” may include a pluralityof compounds, including mixtures thereof.

As used herein the term “method” refers to manners, means, techniquesand procedures for accomplishing a given task including, but not limitedto, those manners, means, techniques and procedures either known to, orreadily developed from known manners, means, techniques and proceduresby practitioners of the chemical, pharmacological, biological,biochemical and medical arts.

As used herein, the term “treating” includes abrogating, substantiallyinhibiting, slowing or reversing the progression of a condition,substantially ameliorating clinical or aesthetical symptoms of acondition or substantially preventing the appearance of clinical oraesthetical symptoms of a condition.

According to some embodiments of the invention there is presented amethod for inserting and removing surgical instruments during alaparoscopic procedure in the body cavity of a subject, comprising:

-   -   inserting a surgical instrument (a grasper, for example)        constructed of two separate parts, a distal operating head        inserted into a body cavity through a conventional laparoscopic        port, by use of a Natural Orifice Transluminal Endoscopic        Surgery (NOTES) instrument, or by some similar method, and a        proximal shaft directly inserted into a body cavity through a        stab incision made in the wall of the body cavity    -   connecting the two parts of the instrument;    -   use of the instrument within the body cavity    -   separation of the two parts following their use;    -   withdrawal of the shaft through its stab incision; and    -   withdrawing of the distal operating head through the port, NOTES        instrument, or similar device.

Connecting and separating distal and proximal portions of the device maybe performed with the assistance of a conventional grasper insertedthrough a trocar.

In some embodiments of the invention a surgical kit comprises a “widetool” and one or more “narrow tools”.

FIG. 1A presents an exemplary embodiment of a wide tool 99, comprising ashaft 100 with a sharp distal end 110 capable of penetrating a bodywall, and a detachable head 200. FIG. 1B shows a wide tool withdetachable head 200 attached.

In some embodiments the shaft of the wide tool is inserted into a bodycavity through the cavity wall, and the distal head of the wide tool isinserted into the body cavity through a trocar and connected to the widetool shaft by manipulation by a grasper or other tool inserted through atrocar. In other embodiments the distal portion of the wide tool may becaused to traverse a portion of the body cavity, and exit the cavitythrough a trocar, where the wide tool head can be connected to the widetool shaft, which is then retracted into the body cavity. In yet otherembodiments the wide tool with head attached may be inserted into thebody cavity through a trocar.

Once the wide tool head is connected to the wide tool shaft andpositioned in the body cavity, the wide tool can be used as describedbelow to connect additional operating heads to additional tools havingshafts introduced (by puncture or very small incisions) into the bodycavity. These may be additional wide tools and/or “narrow tools” asdescribed below.

As may be seen in the exemplary embodiment shown in FIG. 1, the shaft ofthe wide tool may be implemented with a proximal handle 300 shapedsimilarly to a scissor, with one leg of the scissor attached to theoutside of the shaft, and a second leg attached on an actuating rod oractuating cord passing the length of the shaft and providing means formanipulating an operating head when attached thereto by pulling orpushing on the actuating rod or cord and causing it to move backward orforward with respect to the body of the shaft.

FIG. 2 shows a portion of a distal part of such a shaft, showing at “A”a passageway 120 for such an actuating cord 125 or rod 127, at “B” aconnector 130 for fluid (e.g. irrigation or suction), and at “C” apassageway 140 for a stiffening rod 150. FIG. 3 shows such a stiffeningrod 150 positioned alongside the shaft 100 of a wide tool 99, and FIG. 4shows the stiffening rod 150 inserted therein. Such a stiffening rod canbe inserted in the shaft 100 to stiffen and reinforce the shaft, forexample when the shaft is caused to penetrate by force through a bodywall or other tissue. The stiffening rod can then be removed, leaving anempty passageway 140 through which fluids can be caused to flow (e.g.for suction or irrigation), or which may be used for other purposes suchas passing objects therethrough.

FIG. 5 presents an additional embodiment where similar elements arepresented in a slightly different configuration. It is noted that thesmall passage 120, described above as used for passage of an actuatingcord 125 or rod 127, can be used for other purposes, such as for passageof an electrical connection 129. Additional conduits within the shaftmay be supplied as well.

The wide tool may be provided with a solid grasper head, or with agrasper head 210 comprising hollow portions 220 which can be used asconduits for fluids. Such a head 210, comprising a hollow 220, is shownin FIG. 6A, and a detail view of the hollow portion of such a head isshown in FIG. 6B. This hollow portion 220 can be made continuous withthe passage 140 shown in FIG. 2, or with another conduit in the shaft,to enable irrigation, suction, or some similar fluid-related activity.It is noted that although a grasper head with a hollow portion is shownin the figures in the context of tools with detachable heads asdescribed above, graspers and similar surgical tools which comprisehollow portions and are capable of implementing suction activity orirrigation activity in addition to grasping may also be implemented insurgical instruments wherein the grasper head is permanently attached toits shaft.

FIGS. 6C, 6D, and 6E show successive stages of fluid flow in the case ofsuction being applied at point “B” of FIG. 2.

Optionally the wide tool may comprise an electrical power connection,and portions of the shaft may be constructed of insulating materials ormay be covered by insulating materials, as appropriate. Electrical tools270 may be positioned at the operating head or may be incorporated inthe shaft. An example is provided in FIG. 7, which presents a wide toolconfigured as a coagulator 272.

FIG. 8 presents a partial view of a “narrow tool” 101, one or more ofwhich are supplied together with at least one “wide tool” to form a kit,in some embodiments of the present invention. A narrow tool is similarto a wide tool in that it comprises a shaft which comprises a distal endsharp enough to penetrate tissue, a separable operating head useful forperforming a useful function during a surgical procedure, and anattachment configuration (for example, screw threads) enabling to attachand the operating head to a distal portion of the shaft, and to detachit therefrom. In some embodiments the narrow tube comprises a conduitthrough which a wire and/or an activating rod or cord may be passed,which wire or rod or cord may be used to control or activate theoperating head or a portion thereof. Such a conduit is seen positionedin an upper portion of that part of a narrow tool shaft pictured in FIG.8.

It is an advantage of the narrow tool that it may be made extremelythin: in some embodiments the diameter of a narrow tool is between 1 and3 mm. (Note that these dimensions are given by way of example, and arenot to be considered limiting.) Thin shafts of such narrow dimensionscan be caused to penetrate through an abdominal wall (or into any otherbody cavity) with a minimum of damage to tissues through which theypass. In an exemplary method of use, a wide tool is introduced into abody cavity as described above, an operating head for a narrow tool isintroduced into a body cavity through a trocar, and the wide tool isused to grasp the detached narrow-tool head and to attach it to thenarrow tool shaft. In this manner one or many narrow tools can beintroduced into the body cavity and used within the cavity with onlyminimal damage to the cavity walls. Narrow tools so introduced aresimilar to standard laparoscopic tools and can be used by a surgeon withlittle or no special training.

In some embodiments the operating head is constructed of two parts, abase part connected to the shaft (e.g. to a wide tool shaft or to anarrow tool shaft), and a second moveable part connected to anactivating rod positioned in a conduit within the shaft. Moving theactivating rod forward and backward has the effect of moving themoveable head part with respect to the base head part, for exampleopening and closing a grasper as shown in FIG. 9.

In an alternative construction shown in FIG. 10, two moveable parts eachconnected to a common activating rod are also connected to a fixed partof a shaft. Forward and backward movement of the activating rod withrespect to the shaft has the effect of closing and opening the moveableportions of the grasper, as shown in the Figure.

A further alternative construction is presented in FIG. 11, which showsa configuration in which an external activating rod connects to anexternal portion of an operating head, and an internal activating rod,able to advance and retract within the external portion, connects to aninternal portion of the operating head. Advancing and retracting theinternal rod with respect to the external portion causes opening andclosing of the jaws of the grasper. Also of interest in the Figure: notethe form of the distal portion of the shaft 100 in FIGS. 11A and 11D,which distal portion is pointed 102 to facilitate penetration oftissues, but which also comprises screw threads 104 enabling connectionbetween shaft and head. Note also the matching screw threads 103 onouter and inner portions of the operating head, as shown in FIGS. 11Band 11D.

Surgical Support Tools:

Physical Support Structure: In some embodiments of the invention thereis provided a support structure 500 which enables to physically supportor hold organs or parts of organs or other tissues in particularpositions, to enable surgical work to proceed on those organs ortissues, or on organs or tissues in their vicinity. FIG. 12 provides aview of an embodiment where a wide or more typically a narrow tool isused for this purpose. The distal portion of the tube is made topenetrate into the body cavity, the operating head 200 is attached asdescribed above, and the operating head 200 (in the form of a grasper orother tool) is made to seize and hold a portion of the organ or tissueswhose support or immobilization is desired. As shown in the figure, anexternal support device 500 surrounding or otherwise connected to aproximal portion of the tool shaft 100, outside the body cavity, isadjustable and may be adjusted to maintain that proximal portion at adesired position and angle with respect to the body. (In the exemplaryembodiment shown in the figure, a tripod 502 or multi-legged shape 504with adjustable-length legs 506 is used.) Fixing the position of theproximal portion, external to the body, also fixes the position of thedistal portion internal to the body, and thereby fixes also the positionof the tissue or organ grasped by the head.

Tool for removal of operating heads: FIGS. 13-15 present a tool forremoval of operating heads from within the body cavity. FIG. 13 showsthe head removal tool in the form of a sleeve 600 formed to fit on acamera or other visualization device 610 introducible into a body cavitythrough a trocar 620. At the end of the operation or whenever desired,the visualization device may be withdrawn from a trocar, a sleeve 600added to the device as shown in FIG. 13, and the device reinserted. Inuse sleeve 600 may be extended beyond the visualization device. A wideor narrow tool is used to detach an operating head 200 from a tool, andto position it within or attach it to sleeve 600 as shown in FIG. 14.The visualization device together with sleeve 600 and the attachedoperating head 200 can then be removed through the trocar as shown inFIG. 15.

Device for Extracting Tissues:

During the course of an operation it is often necessary to provide forremoving from a body cavity organs or tissues which have been excised,or to provide from removing devices introduced into the cavity duringthe operation. FIGS. 16-18 present a device for doing this.

As shown in FIG. 16, a sleeve 600 is provided which is sized and shapedto be adapted to a visualization device 610 insertable into the bodythrough a trocar 620 or other port. An appropriately sized bag 630 isrolled or folded and stored within the sleeve.

When deployment of the bag is desired, the bag 630 may be unrolled orunfolded using a manipulation device (such as narrow or wide tool withgrasper head) present in the body cavity. The deployed removal bag 630is shown in FIG. 17.

In an alternative embodiment, the removal bag may be provided withflexible straps 640 as shown in FIG. 18. The straps may be manipulatedto open the bag for use, and the bag may be removed from the body cavityby pulling on the straps, which extend beyond the trocar and may begrasped from outside the body of the patient.

Tool for Managing Operating Heads:

According to a further aspect of embodiments of the invention, there isprovided a tool for managing a plurality of operating heads within thebody of a patient.

As described above, operating heads may be inserted into a body cavity(e.g. through a trocar) and there may be attached to one or more toolshafts. In some cases it may be desired to have a plurality of operatingheads (e.g. a plurality of tools of different types) present within abody cavity, and to alternate use of various heads by attaching anddisconnecting them from one or more tool shafts, which shafts remain inplace and need not be removed from the cavity nor reinserted therein.

To facilitate this process a tool organizing device is provided, asshown in FIGS. 19-21.

The tool organizing device may be configured as a cartridge magazine, asa rack, as a shelf, as a set of hooks, or in any other convenientconfiguration.

FIG. 19 shows an exemplary tool rack 650 (a tool organizer device or“head storage tool” is configured as a set of connected hooks) is shownexternal to the body cavity.

In FIG. 20, the tool organizer device (head storage tool) has beeninserted into the body cavity, e.g. through a trocar. To avoidmultiplying large body openings, if a single trocar has been installedand is used for passage of a visualization device into a body cavity,passing the tool organizer (or tool operating heads, or other objects)into the cavity may be done, for example, by removing a visualizationdevice from a trocar, passing the organizing device through the trocarinto the cavity, and then replacing the visualization device in thetrocar.

As shown in the Figure, the tool organizer comprises a penetrating point660 long enough and sharp enough so that if the device is grasped by atool within the cavity the penetrating point may be caused to pass frominside the cavity to the outside of the body, where it may be graspedand held by a surgical tool. This has the effect of immobilizing thetool organizer as shown in FIG. 21.

A plurality of operating heads may then be stored in or on the deviceduring an operation, where they are accessible to being taken up by oneof the available manipulating tools (e.g. wide tool or narrow tool), yetare kept in order and out of the way of on-going surgical manipulations.This situation is presented in FIG. 22.

Attention is now drawn to FIG. 23 which shows a process whereby anoperating head 200 may be attached to a penetrating tool 100 whileoutside the body, as was mentioned above. This procedure is convenientfor attaching an operating head to a wide tool, which wide tool can thenbe used to attach operating heads to a plurality of narrow tools withinthe body cavity. However, for convenience, the procedure shown in FIG.23 can be used to attach heads to narrow tools as well.

As seen in the figure, a shaft 100 is caused to penetrate into a bodycavity in which a trocar 620 or similar port has been inserted. Theshaft is then directed towards and through the trocar (a visualizationdevice using the trocar may be temporarily removed from it for thispurpose), and becomes available outside the body, where the operatinghead may be attached. The shaft is then withdrawn through the trocarback into the body cavity, where it may be used. A similar procedure canbe utilized to remove a head from a shaft before withdrawing the shaftfrom the body.

Example of a Surgical Procedure Using Tools Described in this DocumentRemoval of an Appendix.

-   -   Insert standard trocar (e.g. trocar of 10 mm diameter) into a        body cavity wall, e.g. in the navel.    -   Insert a visualization modality (e.g. a camera), use it to        survey the body cavity, locate the infected appendix.    -   Insert wide tool directly into lower belly.    -   Temporarily remove visualization device, pass through the distal        portion of wide tool so that it extends beyond the trocar and is        outside the body.    -   Affix operating head to wide tool.    -   Withdraw wide tool through trocar into body cavity, replace        visualization device.    -   Introduce narrow tool into the lower belly above the pubis under        guidance of visualization device.    -   Remove visualization device from trocar, introduce operating        head (e.g. dissector) through trocar, restore visualization        device.    -   Use wide tool to grasp dissector head and affix it to narrow        tool shaft, under guidance of visualization tool.    -   Remove visualization device from trocar, introduce tool        organizer, scissor tool, and a tool for immobilization of the        intestine.    -   Fix tool organizer in a place by holding with wide tool and        causing its penetrating point to penetrate the body wall to a        position outside the body, where it is grabbed by a standard        surgical device, thereby immobilizing it.    -   Mount spare operating heads on the organizing tool.    -   Proceed with the operation, cutting, cauterizing, etc. according        to standard surgical procedures as needed, using the various        tools held in readiness by the tool organizer, and changing        operating heads as needed. Appendix is disconnected from the        body, bleeding is cauterized and/or tied. Scissor head mounted        on one of the shafts and used to cut ligatures.    -   Visualization tool removed, sleeve containing tissue bag is        mounted on visualization device which is returned to place        through the trocar.    -   Bag is opened using narrow tool, appendix placed within bag, bag        and visualization device removed from body through trocar.        Visualization tool replaced in cavity.    -   Operation site is irrigated through hollow portion of wide tool.        Hemostasis checked.    -   Body cavity is irrigated, cleaned, inspected.    -   Head removal tool mounted on visualization tool and used to        remove various operating tools, and (usually last) the tool        organizer.    -   Narrow tool(s) withdrawn from body under observation by        visualization tool. Generally no stitching of the penetration        site is required.    -   Removal of visualization device, then of the trocar. Closing of        the opening through which the trocar was inserted.

Attention is now drawn to FIGS. 24-29 which show additional methods forproviding a plurality of operating tools with wide heads within a bodycavity having only a single wide opening.

FIG. 24 shows an operating tool 700 with a wide head 720 and a narrowshaft 710 being inserted through a trocar 620 into a body cavity. Notethat in the figure the wide operating-tool head 720 is positionedoutside the body, and the narrow shaft 710 is inserted through thetrocar into that body. If FIG. 25 the trocar, and the tool within it, isseen to be oriented so that the narrow shaft of the tool is aimedtowards a selected portion of the outer wall of the body cavity.

FIG. 26 shows the shaft (which may have a sharp end 711) starting topuncture the cavity wall, moving from inside the body cavity towards theoutside. A continuation of the process is shown in FIG. 27, in which theshaft has penetrated the cavity wall, and can be grasped from outsidethe patient's body. The shaft can then be draw sufficiently far outsidethe patient's body so that the opposite end of the tool, with operatinghead attached, can be drawn through the trocar and into the body cavity.In the situation shown in FIG. 28, the operating head and distal portionof the tool are within the body cavity, and the tool's shaft is outsidethe body cavity. FIG. 29 shows a handle attached to the tool, which isnow read for surgical work within the body cavity. It the series offigures now described only one tool has been so inserted, but it is tobe understood that a plurality of tools may be inserted into the bodycavity in this manner, each having only a narrow-diameter puncturepenetration of the body cavity wall and a wide operating tool head.

An optional additional embodiment is shown in FIG. 30, where a narrowtrocar 740, only slightly larger than the diameter of the tool shaft710, is positioned on the tool shaft prior to connection of handle 300to shaft. The trocar can be slid down the shaft and into the puncturehole around the shaft, where it serves to facilitate free motion of theshaft during the surgical procedure and also serves to preserve gaspressure within the body cavity if the body cavity is inflated, as isoften the case during surgical procedures.

Attention is now drawn to FIGS. 31-39, which present aspects of asurgical procedure whereby a treatment tool with narrow shaft andrelatively wide treatment head can be introduced into a body cavity andmanipulated through a narrow incision.

FIG. 31 shows a surgical tool 700 partially introduced through a trocarinto a body cavity, with shaft 710 in the body cavity and operating head720 outside the cavity. A handle 301 which comprises an internalstiffener 370 having a sharp point 372 is shown inserted in the handle301, outside the body. (The stiffener is shown in dark color)

FIG. 32 shows the handle 301, with stiffener inserted, penetrating intothe body cavity wall. In FIG. 33 the stiffener 370 has been removed, thehandle 301 remains penetrating the cavity wall. In FIG. 34, the shaft710 of the tool 700 inserted through the trocar, and the handle 301inserted through the cavity wall are oriented towards each other, inFIG. 35 they approach each other and in FIG. 36 they connect. Shaft andhandle are provided with a connecting mechanism 725 such as matchingscrew threads 103, 104 or any other attaching mechanism. A surgeon,manipulating both tools by their portions positioned outside the body,can connect them.

Once handle and tool are connect, the handle can be partially retractedfrom the body, pulling the operating tool head through the trocar andinto the body cavity, as shown in FIG. 37. In FIG. 38 the tool is shownwith operating head within the body cavity and free to move, it's handlebeing outside the body where it can be manipulated by a surgeon. FIG. 39shows the tool approaching a surgical intervention site within the bodycavity.

To remove the tool, the surgeon can use the handle to insert theoperating head of the tool into the trocar, where he can grasp it fromoutside the body, and unscrew it or otherwise disconnect it from thehandle. Thereafter both the tool and the handle can be removed from thebody. The procedure can be used in introduce a plurality of such toolsthrough a single trocar, enabling a surgeon to employ a plurality oftools with wide heads without needing a plurality of wide openings inthe body cavity wall.

It is appreciated that certain features of the invention, which are, forclarity, described in the context of separate embodiments, may also beprovided in combination in a single embodiment. Conversely, variousfeatures of the invention, which are, for brevity, described in thecontext of a single embodiment, may also be provided separately or inany suitable subcombination or as suitable in any other describedembodiment of the invention. Certain features described in the contextof various embodiments are not to be considered essential features ofthose embodiments, unless the embodiment is inoperative without thoseelements.

Although the invention has been described in conjunction with specificembodiments thereof, it is evident that many alternatives, modificationsand variations will be apparent to those skilled in the art.Accordingly, it is intended to embrace all such alternatives,modifications and variations that fall within the spirit and broad scopeof the appended claims.

All publications, patents and patent applications mentioned in thisspecification are herein incorporated in their entirety by referenceinto the specification, to the same extent as if each individualpublication, patent or patent application was specifically andindividually indicated to be incorporated herein by reference. Inaddition, citation or identification of any reference in thisapplication shall not be construed as an admission that such referenceis available as prior art to the present invention. To the extent thatsection headings are used, they should not be construed as necessarilylimiting.

What is claimed is:
 1. A method of performing surgery in a body cavityof a body, the body cavity being separated by a space outside the bodyby a body cavity wall, the method comprising: providing a surgical toolcomprising a shaft and an operating head; inserting a trocar through thebody cavity wall at a first location; inserting the shaft of thesurgical tool from the space outside the body into the body cavitythrough the body cavity wall at a second location; directing the shaftof the surgical tool towards and through the trocar to the space outsidethe body cavity while the shaft of the surgical tool is inserted throughthe body cavity wall at the second location; attaching the operatinghead to the shaft of the surgical tool in the space outside the bodycavity to form an assembled surgical tool; and withdrawing the operatinghead and the shaft of the assembled surgical tool back into the bodycavity.
 2. The method of claim 1, further comprising utilizing theassembled surgical tool within the body cavity to perform an operation.3. The method of claim 2, further comprising removing the operating headfrom the shaft of the assembled surgical tool by passing the operatinghead through the trocar to a position outside the body cavity, anddisconnecting the operating head from the shaft of the assembledsurgical tool.
 4. The method of claim 1, wherein an internal diameter ofthe trocar is 4 mm or larger.
 5. The method of claim 1, wherein a sizeof an opening through the body cavity wall at the second location issmaller than a diameter of the trocar.
 6. The method of claim 1, whereinthe operating head is at least one of a grasper, scissors, a coagulationdevice, a harmonic scalpel, a LigaSure, a needle holder, ligatures, acamera, and a suction device.
 7. The method of claim 1, wherein a widthof the operating head is greater than a width of the shaft.
 8. Themethod of claim 1, wherein the shaft comprises a distal connectingmechanism for connecting to the operating head and a lumen for a movablecontrol element attached to the operating head.
 9. The method of claim1, wherein the body cavity wall is an abdominal wall.
 10. The method ofclaim 1, further comprising inserting a visual device into the bodycavity through the trocar.
 11. A method of surgery, comprising:providing a surgical tool comprising a shaft and an operating head;inserting a trocar through a body cavity wall of a body cavity;inserting the shaft of the surgical tool through the body cavity wall ata location distant from the trocar, so that a proximal portion of theshaft is external to the body cavity; directing a distal portion of theshaft of the surgical tool towards and through the trocar to a spaceoutside the body cavity; attaching the operating head to the shaft ofthe surgical tool while the distal portion of the shaft is in the spaceoutside the body cavity; and withdrawing the operating head and thedistal portion of the shaft of the surgical tool back into the bodycavity.
 12. The method of claim 11, further comprising utilizing theoperating head attached to the shaft within the body cavity to performan operation.
 13. The method of claim 11, further comprising removingthe operating head from the shaft of the surgical tool by passing theoperating head through the trocar to a position outside the body cavity,and disconnecting the operating head from the shaft of the surgicaltool.
 14. The method of claim 11, wherein the shaft of the surgical toolincludes a sharp distal end configured to penetrate the body cavitywall.
 15. The method of claim 11, wherein an internal diameter of thetrocar is 4 mm or larger.
 16. The method of claim 14, wherein theinserting of the shaft of the surgical tool through the body cavity wallof a body cavity includes forming an opening by penetrating the bodycavity wall using the sharp distal end of the shaft.
 17. The method ofclaim 16, wherein a size of the opening through the body cavity wall atthe location distant from the trocar is smaller than a diameter of thetrocar.
 18. The method of claim 11, wherein the operating head is atleast one of a grasper, scissors, a coagulation device, a harmonicscalpel, a LigaSure, a needle holder, ligatures, a camera, and a suctiondevice.
 19. The method of claim 11, wherein a width of the operatinghead is greater than a width of the shaft.
 20. The method of claim 11,further comprising inserting a visual device into the body cavitythrough the trocar.